Nearly half of the observed surgeries and approximately 5% of perioperative medication administrations included a medication error (ME) and/or adverse drug event (ADE), according to a prospective study. This observed rate is much higher than rates reported previously from retrospective surveys. In addition, the new study showed that not only did all of the MEs have the potential for harm, but more than one third of MEs actually led to observed ADEs.
Karen C. Nanji, MD, MPH, from Massachusetts General Hospital in Boston, and colleagues published the observations of anesthesia-trained study staff in Anesthesia. The team observed randomly selected operations at a 1046-bed tertiary care academic medical center.
The researchers note that although the observational nature of the study was the study’s biggest strength, the anesthesia providers may have altered their behavior because they were being observed.
The team observed a total of 277 operations and found that 44.8% of surgeries included an ME or an ADE (44.8%).
Of the 3671 medication administrations, there were 193 MEs and/or ADEs (5.3%; 95% confidence interval, 4.5% – 6.0%), most of which were judged to be preventable (79.3%). The team identified 153 (79.3%) MEs and 91 (47.2%) ADEs, with some events including both MEs and ADEs.
The authors note that among the 153 preventable errors, 99 (64.7%) were judged to be serious, 51 (33.3%) were significant, and 3 (2.0%) were life-threatening.
Before this study, estimates of perioperative ME rates were frequently based on self-reporting. The researchers suggest that self-reporting misses the vast majority of MEs, and therefore should not be used as a reliable assessment of ME rates.
“Nanji and coworkers are to be commended for performing the largest, observational study of anesthesia-related medication events available to date. Their results have confirmed a problem that anesthesiologists have suspected for years. We must now promote change by doing what anesthesiologists do best: breaking down a tough problem into manageable pieces and then a building safer system for patients undergoing anesthesia,” write Beverley A. Orser, MD, PhD, from the University of Toronto, Ontario, Canada, and colleagues.
The researchers suggest specific solutions that have the potential to decrease the incidence of perioperative MEs. These process- and technology-based solutions have the potential to address the root cause of the errors, thereby reducing the incidence of errors.
“In Contributing Factors and Solutions, we identified several strategies to minimize perioperative MEs and/or ADEs, including technology-based interventions and process-based interventions. Examples of technology-based interventions include bar code–assisted syringe labeling systems, point-of care bar code–assisted anesthesia documentation systems, specific drug decision support, and alerts,” the authors write.
In particular, the adoption of a bar code–assisted syringe labeling system can eliminate labeling errors. Also, anesthesia records can be populated immediately, using point-of-care bar code–assisted anesthesia documentation systems.
Dose calculators and maximum dose checking can address wrong dose and wrong drug errors. Connecting infusions to the most proximal intravenous port can prevent inadvertent boluses of intravenous infusions, they explain.
The authors also point out the importance of documenting medications before administration to actually reduce errors, and not just document errors once they have been made. Moreover, any system put in place to reduce medical errors should include reduced opportunity for workarounds. Development of such systems will also require commitment from vendors who are willing to iteratively improve their technology on the basis of user feedback.
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